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Documentation in Long-Term and Home Healthcare Setting01:29

Documentation in Long-Term and Home Healthcare Setting

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Documentation in long-term care facilities and home healthcare settings is crucial for ensuring continuous, coordinated, and comprehensive care for patients. Each setting has its specific documentation processes and tools:
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Methods of Documentation VI: Case Management Model01:15

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The case management model is a multidisciplinary approach that involves healthcare professionals from diverse disciplines, such as physicians, nurses, therapists, social workers, and pharmacists, working collaboratively to address the various needs of patients. Each healthcare professional brings unique expertise and perspectives, contributing to a more comprehensive understanding of the patient's condition and tailoring treatment plans accordingly.
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Continuing care describes the variety of health, personal, and social services provided over a prolonged period. The need for continuing care is increasing because people are living longer. Many people do not have families or others to care for them. Continuing care is mainly for patients who are disabled, functionally dependent, or suffering from a terminal disease. It is available within institutional settings or in homes. Examples include nursing centers or facilities, assisted living,...
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At the different levels of the healthcare system, we see varying methods of healthcare used. These methods include managed care systems, case management, and primary healthcare.
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Health Information Technology (HIT)
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Patient-centered care involves delivering care beyond inpatient hospitalization. Reflective practice can enhance a patient-centered approach. Reflective practice is a process of reasoning that considers all aspects of the present situation, including practicalities, learning from personal practice, and consideration of patient needs. Patients appreciate care decisions made while considering their input. Involving the patient in their care provides the patient with a sense of contribution rather...
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Related Experiment Video

Updated: Jul 9, 2025

Digital Home-Monitoring of Patients after Kidney Transplantation: The MACCS Platform
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Cost Reduction and Utilization Patterns in a Medicare Accountable Care Organization Using Home-Based Palliative Care

Mark Angelo1,2, Abigail Souder3, Angela Poole2

  • 1Supportive Oncology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.

Population Health Management
|November 27, 2023
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Summary

Home-based palliative care (HBPC) services significantly reduce hospitalizations and total costs for accountable care organization (ACO) beneficiaries nearing end of life. This approach improves care efficiency and outcomes for high-need patients.

Keywords:
Medicare cost reductionaccountable carehome-based palliative carepalliative care

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Area of Science:

  • Health Services Research
  • Gerontology
  • Palliative Care

Background:

  • Accountable Care Organizations (ACOs) aim to improve healthcare efficiency and quality.
  • Directing resources to high-need patients is crucial for ACO success.
  • Home-based palliative care (HBPC) addresses needs of seriously ill patients and can lower costs.

Purpose of the Study:

  • To evaluate the impact of HBPC on cost, quality, and utilization for Medicare beneficiaries in an ACO nearing end of life.

Main Methods:

  • Retrospective review of 3418 Medicare Shared Savings Program beneficiaries.
  • Comparison of decedents who received HBPC versus those who did not.
  • Analysis of cost, quality, and utilization patterns.

Main Results:

  • HBPC recipients had a 51% reduction in hospitalizations.
  • HBPC group showed increased hospice utilization (70% vs. 43%).
  • Total cost of care was significantly lower for HBPC recipients ($27,203 vs. $36,089).

Conclusions:

  • HBPC is associated with decreased cost and utilization in an accountable care population nearing end of life.
  • Further research is needed to identify specific care components driving these positive outcomes.